To read more about heart disease and cholesterol, check out this eBook on the Diet–Heart Myth.
It’s hard to overstate the impact that cardiovascular disease (CVD) has in the U.S.. Consider the following:
- Cardiovascular disease affects 65 million Americans.
- Close to one million Americans have a heart attack each year.
- In the U.S., one person dies every 39 seconds of cardiovascular disease.
- 1 of 3 deaths that occurs in the U.S. is caused by cardiovascular disease.
- 1 in 3 Americans have metabolic syndrome, a cluster of major cardiovascular risk factors related to overweight/obesity and insulin resistance.
- The total cost of cardiovascular disease in 2008 was estimated at $300 billion.
To put that last statistic in perspective, the World Health Organization has estimated that ending world hunger would cost approximately $195 billion. One might argue that the $300 billion we spend on treating cardiovascular disease in the U.S. is a necessary expenditure; however, a recent study which looked at the relationship between heart disease and lifestyle suggested that 90% of CVD is caused by modifiable diet and lifestyle factors. (1)
Unfortunately, cardiovascular disease is one of the most misdiagnosed and mistreated conditions in medicine. We’ve learned a tremendous amount about what causes heart disease over the past decade, but the medical establishment is still operating on outdated science from 40-50 years ago.
In this 4-part series, I’m going to debunk 3 common myths about heart disease:
- Eating cholesterol and saturated fat raises cholesterol levels in the blood.
- High cholesterol in the blood is the cause of heart disease.
- Statins save lives in healthy people without heart disease.
In the fourth and final article in the series, I’ll discuss strategies for naturally protecting yourself against heart disease and improving your heart health.
Myth #1: Eating Cholesterol and Saturated Fat Raises Cholesterol Levels in the Blood.
Most of us grew up being told that foods like red meat, eggs and bacon raise our cholesterol levels. This idea is so deeply ingrained in our cultural psyche that few people even question it. But is it really true?
The diet-heart hypothesis—which holds that eating cholesterol and saturated fat raises cholesterol in our blood—originated with studies in both animals and humans more than half a century ago. However, more recent (and higher quality) evidence doesn’t support it.
On any given day, we have between 1,100 and 1,700 milligrams of cholesterol in our body. 25% of that comes from our diet, and 75% is produced inside of our bodies by the liver. Much of the cholesterol that’s found in food can’t be absorbed by our bodies, and most of the cholesterol in our gut was first synthesized in body cells and ended up in the gut via the liver and gall bladder. The body tightly regulates the amount of cholesterol in the blood by controlling internal production; when cholesterol intake in the diet goes down, the body makes more. When cholesterol intake in the diet goes up, the body makes less.
This explains why well-designed cholesterol feeding studies (where they feed volunteers 2-4 eggs a day and measure their cholesterol) show that dietary cholesterol has very little impact on blood cholesterol levels in about 75% of the population. The remaining 25% of the population are referred to as “hyper-responders”. In this group, dietary cholesterol does modestly increase both LDL (“bad cholesterol” and HDL (“good cholesterol”), but it does not affect the ratio of LDL to HDL or increase the risk of heart disease. (2)
In other words, eating cholesterol isn’t going to give you a heart attack. You can ditch the egg-white omelettes and start eating yolks again. That’s a good thing, since all of the 13 essential nutrients eggs contain are found in the yolk. Egg yolks are an especially good source of choline, a B-vitamin that plays important roles in everything from neurotransmitter production to detoxification to maintenance of healthy cells. (3) Studies show that up to 90% of Americans don’t get enough choline, which can lead to fatigue, insomnia, poor kidney function, memory problems and nerve-muscle imbalances. (4)
What about saturated fat? It’s true that some studies show that saturated fat intake raises blood cholesterol levels. But these studies are almost always short-term, lasting only a few weeks. (5) Longer-term studies have not shown an association between saturated fat intake and blood cholesterol levels. In fact, of all of the long-term studies examining this issue, only one of them showed a clear association between saturated fat intake and cholesterol levels, and even that association was weak. (6)
Moreover, studies on low-carbohydrate diets (which tend to be high in saturated fat) suggest that they not only don’t raise blood cholesterol, they have several beneficial impacts on cardiovascular disease risk markers. For example, a meta-analysis of 17 low-carb diet trials covering 1,140 obese patients published in the journal Obesity Reviews found that low-carb diets neither increased nor decreased LDL cholesterol. However, they did find that low-carb diets were associated with significant decreases is body weight as well as improvements in several CV risk factors, including decreases in triglycerides, fasting glucose, blood pressure, body mass index, abdominal circumference, plasma insulin and c-reactive protein, as well as an increase in HDL cholesterol. (7)
If you’re wondering whether saturated fat may contribute to heart disease in some way that isn’t related to cholesterol, a large meta-analysis of prospective studies involving close to 350,000 participants found no association between saturated fat and heart disease. (8) A Japanese prospective study that followed 58,000 men for an average of 14 years found no association between saturated fat intake and heart disease, and an inverse association between saturated fat and stroke (i.e. those who ate more saturated fat had a lower risk of stroke). (9)
That said, just as not everyone responds to dietary cholesterol in the same manner, there’s some variation in how individuals respond to dietary saturated fat. If we took ten people, fed them a diet high in saturated fat, and measured their cholesterol levels, we’d see a range of responses that averages out to no net increase or decrease. (If dietary saturated fat does increase your total or LDL cholesterol, the more important question is whether that’s a problem. I’ll address that in the next article in this series.)
Another strike against the diet-heart hypothesis is that many of its original proponents haven’t believed it for at least two decades. In a letter to the New England Journal of Medicine in 1991, Ancel Keys, the founder of the diet-heart hypothesis said (10):
Dietary cholesterol has an important effect on the cholesterol level in the blood of chickens and rabbits, but many controlled experiments have shown that dietary cholesterol has a limited effect in humans. Adding cholesterol to a cholesterol-free diet raises the blood level in humans, but when added to an unrestricted diet, it has a minimal effect.
In a 2004 editorial in the Journal of American College of Cardiology, Sylvan Lee Weinberg, former president of the American College of Cardiology and outspoken proponent of the diet-heart hypothesis, said (11):
The low-fat, high-carbohydrate diet… may well have played an unintended role in the current epidemics of obesity, lipid abnormalities, type 2 diabetes, and metabolic syndromes. This diet can no longer be defended by appeal to the authority of prestigious medical organizations.
We’ve now established that eating cholesterol and saturated fat does not increase cholesterol levels in the blood for most people. In the next article, I’ll debunk the myth that high cholesterol in the blood is the cause of heart disease.
Research Spotlight: Health Coaching and Heart Health
Behavioral Counseling Dose-Dependently Improves Blood Lipid Levels
Oxidized low-density lipoprotein (LDL) cholesterol plays a critical role in the development of cardiovascular disease (CVD). High circulating levels of LDL cholesterol increase the likelihood that LDL may become oxidized, contributing to CVD pathogenesis. Diet and lifestyle changes have been found to reduce LDL cholesterol, but many patients have trouble sustaining nutrition and lifestyle changes over the long term. Behavioral counseling may help patients at risk for CVD maintain a healthy diet and lifestyle behaviors, and thus support improved long-term health outcomes. A 2019 study sought to examine the combined effects of behavioral counseling and healthy lifestyle changes on LDL cholesterol levels in adults with prehypertension and stage 1 hypertension, who are at an elevated risk of CVD.
- Seven hundred fifty-six adults with prehypertension and stage 1 hypertension were randomized to one of three groups:
- Advice-Only Group: Participants were given information about nutrition and lifestyle approaches for improving CVD risk factors, including dietary sodium restriction, weight loss, exercise, and a “healthy diet.”
- Established Lifestyle Intervention Group: Participants were educated about healthy diet and lifestyle changes and provided with behavioral counseling.
- Established + Dietary Approaches to Stop Hypertension (DASH) Lifestyle Intervention Group: Participants were instructed about healthy diet and lifestyle changes, behavioral counseling, and the DASH diet.
- Subjects in the “Established Lifestyle Intervention” and “Established + DASH Lifestyle Intervention” groups experienced significant reductions in LDL cholesterol, triglycerides, and total cholesterol after six months compared to the “Advice-Only” group.
- For every 10 sessions of behavioral counseling, LDL cholesterol decreased by 6.2 mg/dL.
- The relationship between the number of behavioral counseling sessions attended and reductions in LDL cholesterol and triglycerides was mediated by a decrease in waist circumference, suggesting that the combination of behavioral counseling and lifestyle changes reduces visceral adiposity.
A combination of healthy lifestyle changes and behavioral counseling can reduce LDL cholesterol in individuals with hypertension and may thus reduce their future risk of CVD. Attending more behavioral counseling sessions appears to lead to more significant improvements in CVD risk factors. Frequent health coaching sessions, combined with the administration of nutrition, exercise, sleep, and stress reduction advice, may be a valuable model for improving long-term health in people with CVD risk factors.
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